Singlism – the stereotyping, stigmatizing, and marginalizing of single people, and the discrimination against them – is something I have been talking about for years. One of the most persistent and annoying reactions I get is that singlism doesn’t really exist; or, if it does, it is inconsequential.
Well, that objection should finally get put to rest. One of the most prestigious medical journals in the world, the New England Journal of Medicine, recently published an article making the case that singlism not just exists in medicine, but that it can endanger the lives of patients who are not married. (The word “singlism” was not used, but the point was made.) The article, “Death by Stereotype: Cancer Treatment in Unmarried Patients,” was written by Joan DelFattore and published in the September 5, 2019 issue of the New England Journal of Medicine.
I asked Joan if she would tell us more about this, and I am so grateful that she agreed.
Bella: First, please tell us the main point of your article.
Joan DelFattore: Cancer patients are more likely to receive surgery and radiotherapy if they’re currently married than if they aren’t.
The point of my article is not that this is a new finding, but that it’s been reported in the medical literature for more than thirty years without raising red flags. The medical researchers who’ve revealed this discrepancy speculate, without evidence, that unmarried adults aren’t able to handle those treatments because they’re depressed, addicted, unable to follow medical instructions, and socially isolated.
What I did was to draw on psychological and sociological research, including studies cited by the medical researchers themselves, to demonstrate the fallacy of those assumptions.
Bella: You describe the biases of physicians as implicit. But I wonder whether they are explicit. If you asked those doctors directly about the social support available to married and unmarried people, do you think some of them would voice their stereotypes, unselfconsciously and unapologetically?
Joan DelFattore: My guess is that it’s a combination of the two. Your own research has shown how deeply ingrained those stereotypes of single adults are, and medical school can’t exempt people from absorbing that cultural narrative through their pores. As you well know, the person who holds a bias is likely to see it, not as a deliberate choice, but as a reflection of the way things are.
Take, for example, medical researchers who state that people without spouses lack social support, and then try to substantiate that claim by citing studies of multidimensional social support that don’t even mention the words “marriage,” “marital,” or “spouse.” The belief that marriage and social support are the same thing seems so clearly true to them that they don’t recognize a contradiction when they’re looking straight at it.
In interviews with researcher Nina Cavalli-Bjorkman, some Swedish oncologists suggested that unmarried patients who claim to be happy are either deceiving themselves or embarrassed to admit the truth. They said that right out loud, apparently not seeing anything to be ashamed of. But that doesn’t rule out implicit bias as the source of those remarks. Those oncologists may be deliberately discriminating, or they may be describing a mental image that they can’t distinguish from simple reality.
Bella: Wow, that is so appalling and so insulting. And sadly, they are not the only ones who believe that single people can’t possibly be truly happy.
Bella: In your article, you made a compelling, research-based case that single people often do have social support. Will you also explain the flip side of that—examples in which married people do not have any social support, even though they have a spouse?
Joan DelFattore: That’s an important point. Several of the medical articles I examined briefly mention differences in the quality of marriages, but then they carry right on with their main argument that married people have social support and unmarried people don’t.
And yet, research shows that some spouses are not supportive, and that living in conflict has worse health consequences than living alone. So assuming that a married person has social support might be as inaccurate as assuming that an unmarried person doesn’t. The better approach would be to spell out the help the patient will need and ask if it’s available, rather than assuming that it must/will come from people in specific family relationships.
Bella: The point you make – that many single people do have ample social support, and therefore they can handle difficult treatments – is an important one. I agree that doctors should realize that. But suppose a patient really doesn’t have much social support. Shouldn’t everyone get the opportunity to have the best treatment? I’m reminded of what Cathy Goodwin said in an essay about looking for a ride to get a medical procedure: “Why should I be denied care if I’m single and new in town? For that matter, why must I be a friendly, sociable person who attracts dozens of caring friends? Can’t I be a curmudgeonly hermit and still get medical care?” I understand that cancer treatment is more daunting than just getting a ride, but for people who can afford it, aren’t there trained professionals you can hire? And for people who don’t have that kind of money, maybe they would want to try to get the resources they need though Go Fund Me or some such.
Joan DelFattore: Absolutely, and as you observed in your previous question, that could also be true of some married adults. A medical researcher I interviewed used the example of a patient who needs radiotherapy five days a week for five weeks, implying that an unmarried person wouldn’t have the necessary support. And as you say, that is indeed true of some unmarried patients. Perhaps they’re what Dr. Goodwin called a “curmudgeonly hermit,” or perhaps their marriages recently ended or they just moved to a new location, and thus haven’t yet established a friend network.
But is it really true that spouses can be with each other five days a week for five weeks? For example, what about those who are self-employed, or aren’t paid when they don’t work? True, the Family and Medical Leave Act requires at least some employers to provide time off, but not with pay, and the sick spouse may also be out of work. And what about spouses who are infirm themselves, or responsible for caring for others?
As I see it, the American health care system needs to adapt to the social needs of the 21st century, with fewer women available for caregiving 24/7, and fewer adult children or extended families living nearby. In a profit-based model, patients come in just long enough to have the procedure they’re paying for, and are out the door as soon as they can walk.
I’ve heard that some veterans’ hospitals have residences where patients can stay for a day or two after a procedure. As I understand it, those facilities are not staffed, but other people are around, and the patient doesn’t have to drive or be driven home right away.
In our public conversations about a social safety net, “access” to health care needs to include not only the ability to pay for the procedure, but also things like affordable transportation and aftercare.
Bella: Prestigious journals can be very stingy about the number of words they allow in their articles. Are there any points you wanted to make but couldn’t because of space limitations?
Joan DelFattore: Oh, where do I start? Perhaps the most important addition would have been an answer to an objection I’ve heard repeatedly: that physicians don’t have time to ask about social support. Of course, there’s no doubt that they’re under pressure to see more patients in less time, with burdensome record-keeping added on. But if the presence or absence of social support is a decisive factor in determining eligibility for the best treatment, then physicians can’t responsibly argue that there’s no time to find out what social support an individual patient actually has.
This goes back to what I said when you asked about implicit and explicit bias. If physicians genuinely don’t realize that marital status is not a proxy for social support, then they won’t see a need for further discussion, and they won’t recognize what they’re doing as a personal bias rather than a legitimate medical judgment.